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Assessment Diagnosis Inference Planning Intervention Rationale Evaluation

The patient reported abdominal pain rated at 6/10. The diagnosis was acute pancreatitis based on clinical findings including abdominal guarding and irritability. Acute pancreatitis is an inflammatory process of the pancreas caused by premature activation of pancreatic enzymes that destroy pancreatic tissue, resulting in autodigestion and fibrosis. After 4 hours of nursing interventions including analgesics, bed rest, and quiet environment, the patient reported the pain was relieved and was able to follow the prescribed treatment plan.

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Diolan Novero Bagorio
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1K views2 pages

Assessment Diagnosis Inference Planning Intervention Rationale Evaluation

The patient reported abdominal pain rated at 6/10. The diagnosis was acute pancreatitis based on clinical findings including abdominal guarding and irritability. Acute pancreatitis is an inflammatory process of the pancreas caused by premature activation of pancreatic enzymes that destroy pancreatic tissue, resulting in autodigestion and fibrosis. After 4 hours of nursing interventions including analgesics, bed rest, and quiet environment, the patient reported the pain was relieved and was able to follow the prescribed treatment plan.

Uploaded by

Diolan Novero Bagorio
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOCX, PDF, TXT or read online on Scribd
  • Medical Case Assessment and Plan: Provides a comprehensive framework for assessing, diagnosing, planning, and evaluating a medical case, particularly concerning acute pancreatitis.

ASSESSMENT SUBJECTIVE: Masakit ang tiyan ko as verbalized by the patient.

DIAGNOSIS Acute pain. related to obstruction of pancreatic, biliary ducts, and extension of inflammation to the retroperitoneal nerve plexus as evidenced by irritability and pain scale of 6/10

INFERENCE Acute pancreatitis is a serious and at times lifethreatening inflammatory process of the pancreas. This process is caused by a premature activation of pancreatic enzymes that destroy ductal tissue and pancreatic cells, resulting in autodigestion and fibrosis of the pancreas. The pathologic changes occur in variable degrees. The severity of pancreatitis depends on the extent of inflammation and tissue destruction.

PLANNING

INTERVENTION

RATIONALE

EVALUATION After 4 hours of nursing interventions, the Patient was able to report pain is relieved; follow prescribed therapeutic regimen; and demonstrate use of methods that provide relief.

OBJECTIVE:

Abdominal guarding behavior Inability to concentrate . Irritability Pain scale of 6/10 V/S taken as follows T: 37.0C P: 67 R: 20 BP: 110/ 80

After 4 hours Independent of nursing Investigate Pain is interventions, verbal often the Patient reports of diffuse, will report pain, noting and pain is specific unrelentin relieved; location and g in acute follow intensity. or prescribed hemorrha therapeutic gic regimen; and pacreatitis demonstrate use of methods that provide relief. Maintain bed Decrease rest during stimulatio acute attack n of and provide pancreatic quiet, restful secretions environment. , thereby reducing pain. Reducing Promote abdominal position of pressure comfort. and tension.

Keep environment free of food odors.

Sensory
stimulatio n can activate pancreatic enzymes.

Maintain meticulous skin care, especially in draining abdominal wall fistulas.

Pancreatic
enzymes can digest the skin and tissues of the abdominal wall,

creating abscesse s and ulceration. Collaborative Administer intravenous analgesics as prescribed.

Severe or
prolonged pain can aggravate shock and is more difficult to relieve, requiring larger doses of medicatio n, which can mask underlying problems and complicati ons. Patient should be kept noting by mouth status until pain and nausea subside to limit or reduce release of pancreatic enzymes and resultant pain.

Withhold food and fluid, as indicated.

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION SUBJECTIVE: “Masakit ang tiyan ko” as v
Collaborative  Administer intravenous analgesics as prescribed.  Withhold food a

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